Sequential endoscopy may boost GERD control

A sequential endoscopic approach combining antireflux mucosectomy followed by repeat mucosal ablation improved symptoms and objective reflux measures in patients with gastroesophageal reflux disease who did not respond to medication, according to new study results.

In the retrospective, single-center study of 36 patients with proton pump inhibitor (PPI)–refractory gastroesophageal reflux disease, published in Techniques and Innovations in Gastrointestinal Endoscopy, researchers led by first author Tomasz Klimczak, MD, of the Department of General and Transplant Surgery at the Medical University of Lodz, Poland, evaluated outcomes after antireflux mucosectomy (ARMS) and, in nonresponders, repeat antireflux mucosal ablation (reARMA).

“Unlike previous studies that have primarily assessed ARMS or ARMA as standalone treatments, this investigation explores the sequential combination’s efficacy, hypothesizing that reARMA can provide additional symptom relief in patients who remain refractory to initial ARMS,” the investigators wrote. They used the Frequency Scale for the Symptoms of GERD and the GERD–Health Related Quality of Life score to assess symptom burden, along with objective measures including acid exposure time and the DeMeester score.

ARMS alone achieved clinical success in 25 of 36 patients (69%). Median symptom scores improved markedly, with Frequency Scale scores decreasing from 15 to 5 and GERD–Health Related Quality of Life scores declining from 31 to 6. Acid exposure time declined by 79.2%, from 6.25% to 1.3%, and the DeMeester score decreased by 55.4%, from 28.3 to 12.6. Lower esophageal sphincter function, assessed using an endoscopic pressure study integrated system, normalized to 2 kPa.

Following ARMS, 16 patients (44%) discontinued PPIs. Patients with abnormal baseline acid exposure had worse physiologic measures at baseline but similar symptom scores compared with those with normal exposure.

Eleven patients with persistent or recurrent symptoms after ARMS underwent reARMA at 12 weeks. In this subgroup, clinical success was achieved in eight patients (73%). Median Frequency Scale scores improved from about 20 before reintervention to 4 after, while GERD–Health-Related Quality of Life scores fell from 35–40 to 6. Acid exposure time decreased to 1%, and the DeMeester score improved to 10, indicating normalization of reflux parameters.

Across the full cohort, the sequential strategy was associated with higher success rates than ARMS alone. Clinical success reached 85% with combined therapy versus 65% with a single intervention. Patients undergoing both procedures had lower final symptom scores and improved physiologic outcomes, including acid exposure time of 1% versus 2.1% after ARMS alone and a DeMeester score of 10 versus 12.6.

Comparisons with reARMA alone also favored the staged approach. Patients undergoing both procedures had lower symptom scores and better acid control than those treated with ablation alone, suggesting an added benefit of mucosectomy as the initial step.

No major perioperative or postoperative complications were reported. The procedures were performed using standard endoscopic techniques, with ARMS involving mucosal resection at the gastroesophageal junction and reARMA using argon plasma coagulation to reinforce the antireflux barrier.

The study provides evidence for a step-up endoscopic strategy in patients with refractory disease, particularly those who do not achieve adequate symptom control after initial intervention, noted investigators. Incomplete response to ARMS may reflect anatomical factors, insufficient flap valve restoration, or underlying motility disorders.

The authors noted limitations of the analysis, including its retrospective design, small sample size, lack of a control group, and nonstandardized selection for reARMA. Not all patients underwent repeat objective testing, and reflux hypersensitivity was not systematically assessed, which may have influenced the observed treatment effects.

The findings suggest that “reARMA can serve as a ‘second-stage’ intervention to stabilize GERD control in challenging cases without resorting to [antireflux surgery],” the authors wrote.

They reported no conflicts of interest, and the study received no external funding.

Expert Insight

GI & Hepatology News invited Mohammad A. Al-Haddad, MD, the Naga P. Chalasani Professor of Gastroenterology and Hepatology and Division Director at Indiana University School of Medicine, to weigh in on the study results. He collaborated on the responses with Nwal Hadaki, MD, a postdoctoral research fellow at Indiana University.

Why is this study important?

Dr. Al-Haddad: This study fills an important niche. Most of the existing literature frames ARMS and ARMA as competing options, but the real clinical question is whether they can be used in sequence as part of a graduated, risk-stratified pathway for PPI-refractory GERD patients, who occupy a middle ground between failed medical therapy and fundoplication. The observation that reARMA salvaged roughly 73% of ARMS nonresponders, with congruent improvements in both symptom scores and physiologic measures, supports the idea that a second pass at reinforcing the gastroesophageal junction (GEJ) flap valve can expand the pool of patients successfully managed endoscopically.

How might the findings influence clinical practice?

Dr. Al-Haddad: The findings push us to think of ARMS less as a “one-shot procedure” and more as the first step in a staged approach, with reARMA as a logical salvage option rather than a last resort. That shifts the conversation with non-responders, who until now have mostly been pointed toward fundoplication, and it raises the bar for when surgery actually needs to be discussed. That said, because reARMA candidates here were selected based on clinician judgment rather than specified physiologic or symptomatic thresholds, applying this into practice will require clearer criteria for who should be retreated versus referred for escalation of therapy such as fundoplication.

Where are the knowledge gaps, and what still needs investigation?

Dr. Al-Haddad: Key gaps include the lack of a control arm, absence of standardized reflux-hypersensitivity/phenotyping, short follow-up, and unclear predictors of who benefits from reARMA versus who should proceed directly to surgery. Multicenter prospective trials with standardized pre- and post-procedural assessment, longer follow-up, uniform impedance-pH phenotyping, and specified retreatment thresholds are needed, as is comparison against other step-up options like fundoplication.

Is there anything else you’d like to say about this work?

Dr. Al-Haddad: The authors should be credited for their transparency about limitations such as retrospective design, clinician-discretion selection, confounding by indication when comparing ARMS-only versus sequential groups, which appropriately frames the findings as hypothesis-generating. It's also worth noting the favorable safety profile of such interventions, which is reassuring, given concerns about stenosis or perforation with repeat interventions at the GEJ.

Dr. Al-Haddad and Dr. Hadaki had no disclosures to report.